Emergency Ultrasound Standard Reporting Guidelines

Transcription

1 Emergency Ultrasound Standard Reporting Guidelines October 2011 *heterogenous corrected to heterogeneous on pages 9 & 11, January 2016

2 Emergency Ultrasound Standard Reporting Guidelines: Introduction and Statement of Purpose Developed by members of the ACEP Emergency Ultrasound Section These guidelines represent the product of a working group that was formed based on discussions at the Industry Roundtable subcommittee of the American College of Emergency Physicians (ACEP) Ultrasound Section. The impetus for these guidelines emerged from discussions with emergency ultrasound leaders and industry, both ultrasound manufacturers and electronic medical record (EMR) companies that indicated a need for a more structured method to report and communicate the findings of point-of-care (POC) emergency ultrasound (EUS). This document serves as a resource to clinicians with a wide range of experience, and as such may contain fields or terms that may not be appropriate in all situations or by all clinicians. It is important to note that these guidelines in no way represent required elements of reporting. In fact, in general these guidelines err on the side of including more fields than may be used by most emergency physicians, and it is expected that many fields may remain unused depending on the situations. The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. The purpose of these guidelines is to define fields that may be helpful for POC EUS in a consistent order, with consistent definitions, and in a method that may be easily coded into electronic communications and computer databases. The goal of this document is to accurately report the findings that commonly result from an ultrasound performed by a clinician in the emergency department and to avoid confusion with reports generated by other specialties. We hope to eventually use these guidelines to work with existing reporting structures such as DICOM and initiatives through the Integrated Health Enterprise (IHE) to develop consistent non-proprietary methods of reporting and communicating POC EUS examination findings. Exams included in this draft: FAST Focused Abdominal Aorta Focused Pelvic Ultrasound Obstetrical Non-obstetrical Focused Biliary Focused Renal/ Urinary Tract Focused Thoracic Focused Lower Extremity Venous Focused Cardiac (Echo) Focused Soft Tissue/MSK Focused Ocular In development: Ultrasound guided procedures Testicular Symptom based (hypotension, dyspnea, abdominal pain, chest pain) FORMAT All diagnostic examinations should include: Patient/exam demographics Indications for examination Views Findings Interpretation Quality assurance

3 The first and last portions should be consistent across exam types and are presented here. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions No structures, no objective data can be gathered ly insufficient for diagnosis with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

4 FAST EXAM The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: blunt trauma tachycardia penetrating trauma dyspnea abdominal pain altered mental status chest pain pregnancy hypotension educational Views: Hepatorenal adequate limited not obtained Perisplenic adequate limited not obtained Suprapubic adequate limited not obtained Pericardial adequate limited not obtained R thorax for fluid adequate limited not obtained R thorax for lung sliding adequate limited not obtained L thorax for fluid adequate limited not obtained L thorax for lung sliding adequate limited not obtained Findings: Hepatorenal free fluid: absent present indeterminate Perisplenic free fluid: absent present indeterminate Suprapubic free fluid: absent present indeterminate Right thoracic fluid: present absent indeterminate Right lung sliding present absent indeterminate

5 lung point sign yes no Left thoracic fluid: present absent indeterminate Left lung sliding: present absent indeterminate lung point sign yes no Pericardial effusion: present absent indeterminate size if present small moderate large present size not specified Interpretation: Peritoneal free fluid: present absent indeterminate Pericardial effusion: present absent indeterminate Right thoracic fluid: present absent indeterminate Left thoracic fluid: present absent indeterminate Right lung pneumothorax: present absent indeterminate Left lung pneumothorax: present absent indeterminate Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

6 FOCUSED ABDOMINAL AORTA The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: abdominal pain syncope chest pain hypotension back pain tachycardia flank pain educational pulsatile abdominal mass Views: Proximal Transverse view: complete inadequate Distal Transverse view complete inadequate Sagittal view: complete inadequate Celiac artery: visualized not visualized Bifurcation: visualized not visualized Findings: Aneurysm: present absent indeterminate If present: suprarenal infrarenal both iliac Maximal aortic diameter: cm Interpretation: Sonographic Evidence for Aneurysm: present absent indeterminate If present: cm transverse diameter

7 Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

8 FOCUSED OBSTETRICAL PELVIC ULTRASOUND The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: qualitative (urine) hcg positive quantitative hcg positive Level: pregnant by patient history abdominal pain pelvic pain back pain vaginal bleeding syncope hypotension trauma educational Views obtained: Transabdominal sagittal adequate limited not obtained Transabdominal transverse adequate limited not obtained Endovaginal sagittal adequate limited not obtained Endovaginal coronal adequate limited not obtained Cul-de-sac adequate limited not obtained Left adnexa adequate limited not obtained Right adnexa adequate limited not obtained Hepatorenal space adequate limited not obtained Findings: Uterus: anteverted retroverted indeterminate Cul-de-sac fluid present no significant fluid indeterminate If fluid present: small moderate large amount not specified

9 Intrauterine Pregnancy: present absent indeterminate If present: Yolk sac Yolk sac diameter: mm Fetal pole Measurement: mm Fetal heart FHR: bpm Fetal motion Double decidual sign Gestational sac Diameter: mm For IUP: Location: fundus eccentric indeterminate Myometrial mantle: adequate inadequate indeterminate thickness: mm Crown-rump-length: mm Biparietal diameter: mm Gestational age: w d For No IUP Intrauterine contents: indeterminate empty/endometrial stripe non-specific endometrial fluid collection heterogeneous endometrial material molar pregnancy R adnexa: L adnexa: no significant abnormality ovarian cyst Diameter: mm Simple ovarian mass indeterminate no significant abnormality ovarian cyst Diameter: mm Simple ovarian mass indeterminate complex complex Hepatorenal space fluid: absent present indeterminate Interpretation: no definitive intrauterine pregnancy intrauterine pregnancy live intrauterine pregnancy indeterminate abnormal intrauterine pregnancy molar pregnancy fetal demise

10 Quality assurance: definite ectopic simple ovarian cyst complex ovarian cyst adnexal mass free pelvic fluid free intraperitoneal fluid Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:.

11 Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam FOCUSED Non-Obstetric PELVIC ULTRASOUND Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: qualitative (urine) hcg negative vaginal bleeding quantitative hcg negative syncope abdominal pain hypotension pelvic pain trauma back pain educational Views obtained: Transabdominal sagittal adequate limited not obtained Transabdominal transverse adequate limited not obtained Endovaginal sagittal adequate limited not obtained Endovaginal coronal adequate limited not obtained Cul-de-sac adequate limited not obtained Left adnexa adequate limited not obtained Right adnexa adequate limited not obtained Hepatorenal space adequate limited not obtained Findings: Uterus: anteverted retroverted indeterminate Endometrium: empty endometrial stripe Endometrial stripe max thickness: mm heterogeneous material in endometrium uterine fibroid present Measurement: mm

12 Cul-de-sac: fluid present no significant fluid indeterminate If fluid present: small moderate large R adnexa: ovarian size: amount not specified simple complex normal enlarged indeterminate length: mm width: mm height: mm volume: ml ovarian cyst Diameter: mm Simple complex Color flow: present absent indeterminate not obtained Spectral flow: present absent indeterminate not obtained Resistive index: ovarian mass indeterminate L adnexa: ovarian size: normal enlarged indeterminate length: mm width: mm height: mm volume: ml ovarian cyst Diameter: mm Simple complex Color flow: present absent indeterminate not obtained Spectral flow: present absent indeterminate not obtained Resistive index: ovarian mass indeterminate Interpretation: No sonographic evidence of gynecological pathology. ovarian cyst: simple complex sonographic evidence suggestive of ovarian torsion adnexal mass fibroid(s) sonographic evidence of abnormal free fluid in the pelvis Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely

13 Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

14 FOCUSED BILIARY The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: abnormal labs abdominal pain jaundice pancreatitis fever educational Views obtained: Gallbladder long axis: adequate limited not obtained Gallbladder short axis: adequate limited not obtained Common bile duct: adequate limited not obtained Main lobar fissure: visualized not visualized Portal vein: visualized not visualized Findings: Gallstone(s): present absent indeterminate If stones present: single multiple largest measured: mm mobile non-mobile in fundus in body in neck Gallbladder wall: thickened not thickened indeterminate Wall thickness: mm

15 Pericholecystic fluid: present absent indeterminate Sonographic Murphy s sign: present absent indeterminate Common Bile Duct: normal enlarged indeterminate Largest Diameter: mm Biliary Sludge: present absent indeterminate Polyp: present absent indeterminate Adenomyomatosis present absent indeterminate Transverse gallbladder diameter: mm Longitudinal gallbladder diameter: mm Interpretation: No significant biliary pathology identified Cholelithiasis without sonographic evidence of cholecystitis Cholelithiasis with sonographic evidence of cholecystitis Sonographic evidence of acalculous cholecystitis Choledocholithiasis Polyps Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

16 FOCUSED RENAL/URINARY TRACT The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: abdominal pain flank pain back pain hematuria urinary retention dysuria acute renal failure anuria post-void educational Views obtained: Right kidney long axis (coronal): adequate limited not obtained Right kidney short axis: adequate limited not obtained Left kidney long axis (coronal): adequate limited not obtained Left kidney short axis: adequate limited not obtained Transverse bladder: adequate limited not obtained Sagittal bladder: adequate limited not obtained Findings: Right kidney Hydronephrosis: present absent indeterminate If present: mild moderate severe present degree unspecified Hydoureter: present absent indeterminate Kidney stones: present absent indeterminate If present: size of largest stone: mm

17 stone location(s): parenchyma renal pelvis UPJ Ureter UVJ Renal Cyst: present absent indeterminate If present: simple complex Diameter mm Extra-renal Pelvis: present absent indeterminate Duplicated Ureteral System: present absent indeterminate Left kidney Hydronephrosis: present absent indeterminate If present: mild moderate severe present degree unspecified Hydoureter: present absent indeterminate Kidney stones: present absent indeterminate If present: size of largest stone: mm stone location(s): parenchyma renal pelvis UPJ Ureter UVJ Renal Cyst: present absent indeterminate If present: simple complex Diameter mm Extra-renal Pelvis: present absent indeterminate Duplicated Ureteral System: present absent indeterminate Bladder Dimensions width: mm volume: ml Right ureteral jet: Left ureteral jet: height: mm depth: mm present absent indeterminate not assessed present absent indeterminate not assessed Interpretation: No sonographic evidence of renal tract obstruction Hydronephrosis present left right bilateral mild moderate severe present, degree not specified Hydroureter present left right bilateral Nephrolithiasis left right bilateral parenchyma UPJ UVJ Renal Cyst left right bilateral simple complex

18 Bladder Size distended collapsed normal Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

19 FOCUSED THORACIC The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: dyspnea hypotension chest pain blunt thoracic trauma pleurisy penetrating thoracic trauma hypoxia educational Views: Right anterior/ superior thorax: adequate limited not obtained Right lateral/ inferior thorax: adequate limited not obtained Left anterior/ superior thorax: adequate limited not obtained Left lateral/ inferior thorax: adequate limited not obtained Findings: Right thorax lung sliding: present absent indeterminate lung point sign: present absent indeterminate Interstitium: a-lines: present absent indeterminate b-lines: present absent indeterminate anterior/ superior region: present (greater than 3 per view) absent inferior/ lateral region: present (greater than 3 per view) absent pleural effusion: present absent indeterminate If present: small large

20 anechoic complex lung consolidation: present absent indeterminate air bronchograms: present absent indeterminate other: Left thorax lung sliding: present absent indeterminate lung point sign: present absent indeterminate Interstitium: a-lines: present absent indeterminate b-lines: present absent indeterminate anterior/ superior region: present (greater than 3 per view) absent inferior/ lateral region: present (greater than 3 per view) absent pleural effusion: present absent indeterminate If present: small large anechoic complex lung consolidation: present absent indeterminate air bronchograms: present absent indeterminate Interpretation: No sonographic evidence of acute pulmonary disease Pneumothorax left right bilateral Pleural effusion left right bilateral Alveolar interstitial syndrome (focal) Alveolar interstitial syndrome (diffuse) Lung consolidation left right bilateral other: Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

21 FOCUSED LOWER EXTREMITY VENOUS The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: leg pain: left right bilateral leg swelling: left right bilateral leg erythema: left right bilateral dyspnea tachypnea pleurisy educational Views: Right saphenofemoral junction: adequate limited not obtained Right common femoral vein: adequate limited not obtained Right femoral vein: adequate limited not obtained Right popliteal vein: adequate limited not obtained Right popliteal trifurcation: adequate limited not obtained Left saphenofemoral junction: adequate limited not obtained Left common femoral vein: adequate limited not obtained Left femoral vein: adequate limited not obtained Left popliteal vein: adequate limited not obtained Left popliteal trifurcation: adequate limited not obtained Findings:

22 Right leg Saphenofemoral junction: Common femoral vein: Femoral vein: Popliteal vein: Popliteal trifurcation: Left leg Saphenofemoral junction: Common femoral vein: Femoral vein: Popliteal vein: Popliteal trifurcation: compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate compressible NOT compressible indeterminate Interpretation: no sonographic evidence of deep vein thrombosis DVT present Location(s): R saphenofemoral junction R CFV R FV R popliteal indeterminate for DVT R popliteal trifurcation L saphenofemoral junction L CFV L FV L popliteal L popliteal trifurcation Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

23 FOCUSED CARDIAC ULTRASOUND The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: cardiac arrest chest wall injury hypotension dyspnea shock syncope chest pain tachypnea shortness of breath fever tachycardia educational palpitations Views: Subxiphoid (4 chamber): adequate limited not obtained Parasternal long axis: adequate limited not obtained Parasternal short axis: adequate limited not obtained Subxiphoid (long axis, IVC view): adequate limited not obtained Apical four-chamber: adequate limited not obtained Findings: Pericardial effusion: present absent indeterminate size if present small moderate large present size not specified Evidence of tamponade IVC plethoric R atrial collapse R ventricular collapse Excessive mitral inflow variation

24 Global Ventricular Function: hyperdynamic normal reduced severely reduced asystole indeterminate Right Ventricular Size: normal dilated indeterminate Signs of RV strain RV hypokinesis Paradoxical septal motion McConnell s Sign Tricuspid regurgitation Max velocity: m/s RV hypertrophy Thoracic aorta: present absent indeterminate Aortic root: mm Thoracic aorta diameter: mm IVC: normal dilated collapsed indeterminate Maximum diameter: mm Minimum diameter: mm Collapse: >50% <50% Interpretation: No sonographic evidence of significant cardiac dysfunction No sonographic evidence of significant pericardial effusion Pericardial effusion small moderate large present size not specified Pericardial effusion with evidence of pericardial tamponade Global ventricular function: hyperdynamic normal reduced severely reduced No cardiac activity/ Cardiac standstill No sonographic evidence of RV size dilation RV dilation No sonographic evidence of volume depletion Sonographic findings suggestive of volume depletion Dilated IVC No evidence of sonographic aortic root dilation Dilated Aortic Root Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely

25 Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

26 SOFT TISSUE/MUSCULOSKELETAL The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/ exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: Swelling Mass Decreased Range of Motion Redness Fever Deformity Pain Foreign Body Educational Views: Skin and subcutaneous tissue: adequate limited not obtained Muscle: adequate limited not obtained Tendon: adequate limited not obtained Joint: adequate limited not obtained Bone: adequate limited not obtained Findings: Skin and subcutaneous tissue: Tissue thickness normal thickened indeterminate Thickness mm Tissue Echogenicity normal increased indeterminate Cobblestoning normal increased indeterminate Subcutaneous Collection present absent indeterminate If present Diameter mm Muscle: Appearance normal irregular indeterminate Echogenicity normal increased indeterminate

27 Collection present absent indeterminate Tendon: Appearance normal irregular indeterminate Defect present absent indeterminate Joint: fluid no fluid indeterminate Bone: Cortex Appearance normal irregular indeterminate If irregular aligned angulated/misaligned Interpretation: No sonographic evidence of soft tissue abnormality No sonographic evidence of musculoskeletal abnormality Cellulitis location: Abscess location: Joint Effusion location: Tendon Injury complete partial indeterminate Fractured Bone location: Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments:

28 OCULAR The elements that are BOLDED represent the core emergency ACEP views, findings and interpretations for each application. Patient/exam demographics: Patient name: Patient gender: M F DOB: / / MR#: Bar Code/Patient Identifier: Hospital Name: Date and time of exam: / / Exam type: Diagnostic Educational Procedural Clinical category: Resuscitative Symptom based Therapeutic Unknown/ other Initial exam Repeat exam Primary person obtaining/ interpreting images: Secondary person obtaining/ interpreting images: Additional person(s) obtaining/ interpreting images: Indication(s) for exam: eye pain eye/orbital trauma vision change visual loss head injury suspected foreign body headache educational Views: Right eye transverse: adequate limited not obtained Right eye longitudinal: adequate limited not obtained Left eye transverse: adequate limited not obtained Left eye longitudinal: adequate limited not obtained Findings: Right eye Retinal contour: normal abnormal/ detached indeterminate Lens: normally located dislodged indeterminate Vitreous body: anechoic hyperechoic density indeterminate Optic nerve sheath: enlarged normal indeterminate ONSD: mm Left eye Retinal contour: normal abnormal/ detached indeterminate

29 Lens: normally located dislodged indeterminate Vitreous body: anechoic hyperechoic density indeterminate Optic nerve sheath: enlarged normal indeterminate ONSD: mm Interpretation: No acute abnormalities identified Retinal Detachment left right bilateral Lens dislocation left right bilateral Vitreous Hemorrhage left right bilateral Intraocular Foreign body left right bilateral Increased ONSD left right bilateral Quality assurance: Suggested Quality Assurance Grading Scale Grading Scale Definitions ly insufficient for diagnosis No structures, no objective data can be gathered with some technical or other flaws imaged well and diagnosis easily imaged with excellent image quality and diagnosis completely Image quality Accuracy of interpretation of images as presented TP TN FP FN Accuracy of interpretation of images as compared to gold standard (ie, CT, operative report) TP TN FP FN Comments: